The National Diabetes Audit (NDA) provides a comprehensive view of diabetes care in England and Wales and measures the effectiveness of diabetes healthcare against NICE Clinical Guidelines and NICE Quality Standards.

**Key findings**

- This short report presents the top level findings from the 2016-17 NDA. A full report will be published in March 2018.
- Fewer people with Type 1 than with Type 2 and other diabetes receive their annual checks.
- The last four years have seen improvements in the combined 3 treatment target achievement in both Type 1 and Type 2 and other diabetes.
- Timely offers of structured education have improved over the last three years.

## Contents

| Section | Page | |--------------------------|------| | Introduction | 3 | | Care Processes | 4 | | Treatment Targets | 5 | | Structured Education | 6 | | Definitions | 7 | Introduction

The National Diabetes Audit (NDA) supports improvement in the quality of Diabetes care by enabling participating NHS services and organisations to:

- Assess local practice against NICE guidelines
- Compare their care and care outcomes with similar services and organisations
- Identify gaps or shortfalls that are priorities for improvement
- Identify and share best practice
- Provide comprehensive national pictures of diabetes care and outcomes in England and Wales

This short report presents the top level findings from the 2016-17 NDA. A full report will be published in March 2018.

Audit conducted in collaboration with:

The Healthcare Quality Improvement Partnership (HQIP). The National Diabetes Audit (NDA) is part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP) which is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and funded by NHS England. HQIP is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. HQIP holds the contract to manage and develop the NCAPOP Programme, comprising more than 30 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions. The programme is funded by NHS England, the Welsh Government and, with some individual audits, also funded by the Health Department of the Scottish Government, DHSSPS Northern Ireland and the Channel Islands.

NHS Digital is the new name for the Health and Social Care Information Centre. NHS Digital managed the publication of the 2016-2017 annual report.

Diabetes UK is the largest organisation in the UK working for people with diabetes, funding research, campaigning and helping people live with the condition.

Supported by:

The national cardiovascular intelligence network (NCVIN) is a partnership of leading national cardiovascular organisations which analyses information and data and turns it into meaningful timely health intelligence for commissioners, policy makers, clinicians and health professionals to improve services and outcomes. Care Processes

All people with diabetes aged 12 years and over should receive each of the nine NICE recommended care processes annually and, when diagnosed, attend a structured education programme.

| Nine Annual Care Processes for all people with diabetes aged 12 and over | |---------------------------------------------------------------| | **Responsibility of Diabetes Care providers (included in the NDA 8 Care Processes)** | | 1. HbA1c (blood test for glucose control) | 5. Urine Albumin/Creatinine Ratio (urine test for early kidney disease) | | 2. Blood Pressure (measurement for cardiovascular risk) | 6. Foot Risk Surveillance (foot examination for foot ulcer risk) | | 3. Serum Cholesterol (blood test for cardiovascular risk) | 7. Body Mass Index (measurement for diabetes management) | | 4. Serum Creatinine (blood test for kidney function) | 8. Smoking History (question for cardiovascular risk) | | **Responsibility of NHS Diabetes Eye Screening (screening register drawn from practices)** | | 9. Digital Retinal Screening (photographic eye test for diabetic eye disease) |

Time Series

Table 1: Percentage of people with diabetes receiving NICE recommended care processes by care process, diabetes type and audit year

| | Type 1 | Type 2 and other | |----------------------|--------|------------------| | | 2012-13 | 2013-14 | 2014-15 | 2015-16 | 2016-17 | 2012-13 | 2013-14 | 2014-15 | 2015-16 | 2016-17 | | HbA1c | 79.8 | 80.9 | 83.2 | 83.7 | 84.3 | 93.1 | 93.5 | 94.8 | 95.0 | 95.1 | | Blood pressure | 87.7 | 87.0 | 89.0 | 89.1 | 90.3 | 95.4 | 94.9 | 96.1 | 95.7 | 96.2 | | Cholesterol | 77.3 | 77.4 | 78.7 | 79.1 | 79.9 | 91.9 | 92.4 | 92.8 | 92.7 | 92.7 | | Serum creatinine | 80.3 | 78.8 | 80.5 | 81.5 | 82.7 | 93.2 | 93.4 | 94.5 | 94.7 | 95.0 | | Urine albumin | 56.5 | 63.9 | 55.9 | 50.2 | 50.1 | 74.7 | 84.4 | 74.6 | 66.7 | 65.2 | | Foot surveillance | 71.5 | 70.7 | 72.4 | 72.9 | 69.5 | 85.8 | 86.2 | 86.7 | 86.7 | 79.4 | | BMI | 83.3 | 76.8 | 74.9 | 75.2 | 75.3 | 90.9 | 85.7 | 83.1 | 82.7 | 83.1 | | Smoking | 79.2 | 77.4 | 77.9 | 78.5 | 79.2 | 86.3 | 85.5 | 85.2 | 85.2 | 85.5 | | Eight care processes | 40.8 | 44.5 | 38.7 | 36.5 | 33.7 | 61.2 | 67.6 | 58.7 | 53.7 | 47.6 |

Key Finding

- Fewer people with Type 1 than with Type 2 and other diabetes receive their annual checks.
- Urine albumin and foot surveillance are most often missed out. Treatment Targets

NICE recommends treatment targets for HbA1c (glucose control), blood pressure and serum cholesterol:

- Target HbA1c reduces the risk of all diabetic complications.
- Target blood pressure reduces the risk of cardiovascular complications and reduces the progression of eye disease and kidney disease.
- Target cholesterol reduces the risk of cardiovascular complications.

Time Series

Table 2: Percentage of people with diabetes achieving their treatment targets by diabetes type and audit year

| | Type 1 | Type 2 and other | |----------------------|-----------------|------------------| | | 2012-13 | 2013-14 | 2014-15 | 2015-16 | 2016-17 | 2012-13 | 2013-14 | 2014-15 | 2015-16 | 2016-17 | | HbA1c ≤ 58 mmol/mol | 27.2 | 29.4 | 29.9 | 29.2 | 30.2 | 64.9 | 66.8 | 66.1 | 65.7 | 66.8 | | Blood pressure < 140/80 | 73.4 | 76.4 | 76.4 | 74.2 | 75.8 | 68.6 | 73.6 | 74.2 | 73.6 | 74.2 | | Cholesterol < 5mmol/L | 70.2 | 71.5 | 71.3 | 70.8 | 69.4 | 76.7 | 77.8 | 77.5 | 77.1 | 76.0 | | Meeting all three treatment targets | 16.1 | 18.6 | 18.9 | 18.1 | 18.9 | 37.3 | 41.4 | 41.0 | 40.2 | 40.8 |

Key Finding

- The last four years have seen improvements in the combined 3 treatment target achievement in both Type 1 and Type 2 and other diabetes. Structured Education

Diabetes structured education is quality assured training that provides people with diabetes, their family and their carers with the knowledge and confidence to self-manage a long-term condition.

Diabetes Structured Education courses deliver information, training and support on how to manage diabetes through diet, physical activity and medication. Essentially they are providing the foundation support for diabetes self-management.

Time Series

Figure 1: Percentage of people diagnosed with diabetes that were offered structured education, by year of diagnosis and diabetes type, 2015-16

| | Type 1 | Type 2 and other | |----------------------|--------|------------------| | | 2013 | 2014 | 2015 | 2013 | 2014 | 2015 | | Offered Structured Education within 12 months of diagnosis | 24.4 | 35.7 | 41.1 | 54.0 | 69.2 | 77.0 | | Attended Structured Education within 12 months of diagnosis | 2.3 | 3.2 | 3.2 | 6.4 | 6.7 | 7.1 |

Key Finding

- Timely offers of structured education have improved over the last three years
- The apparently low rates of attendance may be due to incomplete recording of attendance data in GP electronic records. Definitions

Diabetes

Diabetes is a condition where the amount of glucose in the blood is too high because the pancreas doesn’t produce enough insulin. Insulin is a hormone produced by the pancreas that allows glucose to be used as a body fuel and other nutrients to be used as building blocks. There are two main types of diabetes: Type 1 diabetes (no insulin); Type 2 diabetes (insufficient insulin)

Care Processes (NICE recommends all of these at least once a year)

Blood Pressure is a measurement of the force driving the blood through the arteries. Blood pressure readings contain two figures, e.g. 130/80. The first is known as the systolic pressure which is produced when the heart contracts. The second is the diastolic pressure which is when the heart relaxes to refill with blood.

BMI measurement – Body Mass Index calculated from weight and height to classify under, normal and over-weight

Serum creatinine – this blood test is used as measure kidney function

Cholesterol - this blood test measures a type of fat that can damage blood vessels

Foot check - this examination checks the blood supply and sensation (feeling) in the feet. Loss of either is a risk for foot disease

Smoking Status - this records whether the person is a smoker. Smoking increases the diabetic risk for heart attacks and stroke

HbA1c – this is a blood test for average blood glucose levels during the previous two to three months.

Treatment Targets (NICE defines target levels to reduce risks of complications for people with diabetes)

HbA1c - the closer this is to normal (less than 42mmol/mol) the lower is the risk of all long term complications of diabetes

Cholesterol – reducing cholesterol levels lowers the risk of heart attacks and strokes

Blood Pressure – high levels are a risk for heart attacks and strokes; they also drive progression of eye and kidney disease

Specialist Service

This is a service (often hospital based but sometimes delivered in a community setting) which includes diabetes specialists working in multidisciplinary teams. These teams usually comprise physicians (diabetologists), diabetes specialist nurses and dieticians; it may also include clinical psychologists